High-income countries can learn vital lessons from low- and middle-income countries (LMICs) which, through persistence, manage to form much-needed public-health structures that harmonize with pre-existing local public-health systems. (1) Crucial to this developmental process is the extent to which concepts of ethics are incorporated, in meaningful ways, into determinations of which public-health structures are to be formed, how they are to be created, why they need to be prioritized over others, and who should be their beneficiaries and trustees. Scientific progress is a significant basis for public-health change, but the field also invests in value-laden concepts and responds daily to sociopolitical, cultural, and evaluative concerns. The concepts that drive much of public-health practice are shaped by the collective and individual mores that define social systems.

This paper seeks to describe the ethics processes in play when public-health mechanisms are established in LMICs by focusing on two cases where ethics enjoyed a crucial role in producing positive institutional change in public-health policy. Our specific aims are threefold: first, we introduce a view of the relationship between ethics and public health; second, we provide a conceptual framework for ethical analysis of health system events, noting how this approach might enhance the power of existing frameworks; and third, we demonstrate the interplay of these frameworks through the analysis of a programme to enhance road safety in Malaysia and an initiative to establish a national ethics committee in Pakistan. We conclude that while ethics is gradually being integrated into public-health policy decisions in many developing health systems, it is often implicit and undervalued. We hope that this paper will highlight the need for both analysing public-health decision-making from an ethical perspective. (2)

Ethics and health systems

Health systems are defined by WHO as "all the activities whose primary purpose is to promote, restore or maintain health". (1) This definition focuses on those initiatives taken with the main intent of health production (e.g. a vaccination programme), as opposed to external initiatives that have a positive effect on health (e.g. education). In LMICs, these systems face several challenges including under-investment, lack of human capacity, lack of public satisfaction, inadequate utilization and poor health outcomes. (3-5) Health policymaking and public-health practice in such a context involves complex processes where a mix of experiences, politics, evidence, finance, values and ethics all interweave; the failure of any one component can be fatal to any policy.

The search for value-based and ethical policies has recently gained momentum and the global literature has called for further exploration of the role of ethics in public health. (6) In particular, consideration of the situation in LMICs and analysis of case studies has been advocated. (2,7) While there have been extensive explorations of public-health policy in LMICs (such as by WHO), they have tended to focus on the attributes of specific health policies and systems rather than the role of ethics in the policy process.

Several prominent ethicists have provided useful frameworks for analysing public-health programmes, (8) research activities, (9) health policy reforms (10) and public-health practices. (11-13) Drawing from this previous work, we propose that ethics can also be viewed and studied more broadly as an integral component of health systems development. In this form, ethics is an organizational, development-oriented force that provides both methodological and motivational support to public-health practitioners and policy-makers. Crucial to this conceptualization of ethics through the lens of public-health and health systems is knowledge of society and social institutions, which differs from knowledge of diseases or nature-society interactions. …

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